eMedicine Specialties > Dermatology > Psychocutaneous Diseases

Dysmorphophobia

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Coauthor(s): Wanda M Patterson, MD, Department of Dermatology, UMDNJ-New Jersey Medical School; O Joseph Bienvenu III, MD, PhD, Assistant Professor, Department of Psychiatry, Johns Hopkins University School of Medicine; M Peter Chodynicki, MD, Staff Physician, Department of Psychiatry, Johns Hopkins University School of Medicine; Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Contributor Information and Disclosures

Updated: Jul 17, 2009

Introduction

Background

Dysmorphophobia has been described for more than a century.1 This psychiatric condition, also termed body dysmorphic disorder (BDD),2 is marked by a fixation on an imaginary flaw in the physical appearance. In cases in which a minor defect truly exists, the individual with body dysmorphic disorder exhibits an inordinate amount of anguish. Body dysmorphic disorder often is encountered in dermatologic and cosmetic surgery settings.3 This disorder traditionally has been labeled dysmorphic syndrome. Dysmorphophobic symptoms in a dermatologic setting have been termed dermatological hypochondriasis, and in individuals without apparent cutaneous lesions, the condition is termed dermatologic nondisease.4

Body dysmorphic disorder results in significant suffering, occupational dysfunction, and/or social malaise. Individuals with body dysmorphic disorder have variable degrees of awareness concerning the psychiatric nature of the illness. Many people continue to agonize about an imagined defect although they are cognizant that their concerns are excessive. Other people with dysmorphophobia are regarded as delusional and have no insight into their unusual behavioral tendencies.5

Frequency

United States

As much as 1% of the population may have dysmorphophobia.6 One study demonstrated that the prevalence of body dysmorphic disorder appears to be significantly higher among people receiving dermatologic care. Of people receiving dermatologic care, 11.9% were diagnosed with this condition.7

Mortality/Morbidity

People with dysmorphophobia frequently develop major depressive episodes and are at risk for suicide.8 They also may exhibit violent behavior toward their treatment providers.

  • In many cases, individuals with body dysmorphic disorder experience drastic social and occupational dysfunctions that may progress to the point of social isolation.
  • Embarrassment and fear of being scrutinized or mocked cause these individuals to avoid social situations and intimate relationships. Often victims of poor self-image, these individuals do not demonstrate sufficient social skills and frequently are single or divorced.
  • People with dysmorphophobia may believe firmly that a marked change in their perceived body defect is a prerequisite to their happiness and well-being.

Sex

The male-to-female ratio for dysmorphophobia appears to be equal. Males and females tend to focus on different types of perceived defects.9,10

Age

The onset of dysmorphophobia usually occurs in the teenage years; however, average age in people receiving dermatologic care is 33.7 years.

Clinical

History

A typical case presentation of dysmorphophobia (illustrating a number of key features of body dysmorphic disorder) is a 32-year-old male stockbroker who presents to the dermatologist because of concerns about excessive hair loss. The only evidence of this is a possibly receding hairline, which the dermatologist would not have noticed if the patient had not reported it. The patient spends hours each day checking his hair in the mirror and becomes upset when he finds fallen strands in his shower drain. He is self-conscious around others, has dated only occasionally, and currently is demoralized. He has seen numerous dermatologists and plastic surgeons and has undergone 2 cosmetic rhinoplasty operations. When discussing his plight, he bursts into tears and admits recent thoughts of suicide. He believes he is too hideous to attract a partner.

Typical presenting factors for the condition are as follows:

  • Dysmorphophobia usually takes a chronic course. A 12-month follow-up prospective study of its course indicated that in studies with similar methods, it tends to be chronic, with remission probabilities lower than reported for mood disorders, most anxiety disorders, and personality disorders in studies with similar methods.11
  • People with dysmorphophobia often have a history of multiple visits to dermatologists and cosmetic surgeons with resulting unsuccessful treatment.
  • Repeated visits may signify an attempt to gain reassurance concerning the individual's appearance; however, explaining that the physical defect is either nonexistent or minor is futile. Individuals with dysmorphophobia will continue to agonize over perceived flaws.
  • Many people with dysmorphophobia go to great lengths to conceal their defect using items such as wigs, hats, and makeup.
  • Individuals with body dysmorphic disorder often develop compulsive habits (eg, frequent mirror checking, exorbitant grooming, skin picking).
  • Recognizing the symptoms early is crucial, since repeated investigations can result in needless use of resources, time, and money.
  • The presence of body dysmorphic disorder in obsessive-compulsive disorder patients is associated with poor insight into obsessional beliefs and higher morbidity, reflected by a higher number of psychiatric comorbid disorders in general.12

Physical

  • Any body part can be a source of distress; however, the body areas noted most frequently are the skin, hair, and nose.
  • Complaints vary widely, including preoccupation with wrinkles, spots, acne, and large pores.
  • Vascular markings, greasiness, scars, paleness, redness, excessive hairiness, and thinning of hair also are encountered commonly as complaints.13
  • Folliculitis and scarring may be a product of skin picking and plucking of nonexistent hairs; these often result in exacerbation of distress.14

Causes

Heredity may contribute to development of the illness. The prevalence of dysmorphophobia is 4 times higher in first-degree relatives of people with dysmorphophobia than in relatives of probands without the condition. This condition appears to be related to obsessive-compulsive disorder, since it occurs frequently in people with obsessive-compulsive disorder and their relatives, and it responds to the same medications.15,16,17,18

More on Dysmorphophobia

Overview: Dysmorphophobia
Differential Diagnoses & Workup: Dysmorphophobia
Treatment & Medication: Dysmorphophobia
Follow-up: Dysmorphophobia
References
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References

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  2. McElroy SL, Phillips KA, Keck PE Jr, Hudson JI, Pope HG Jr. Body dysmorphic disorder: does it have a psychotic subtype?. J Clin Psychiatry. Oct 1993;54(10):389-95. [Medline].

  3. Jakubietz M, Jakubietz RJ, Kloss DF, Gruenert JJ. Body dysmorphic disorder: diagnosis and approach. Plast Reconstr Surg. May 2007;119(6):1924-30. [Medline].

  4. Cotterill, JA, Millard, LG. Psychocutaneous disorders. In: Champion RH, Rook A, Ebling FJ, Wilkinson DS, eds. Rook/Wilkinson/Ebling Textbook of Dermatology. 6th ed. London, England: Blackwell Science; 1998:2792-4.

  5. Phillips KA, McElroy SL. Insight, overvalued ideation, and delusional thinking in body dysmorphic disorder: theoretical and treatment implications. J Nerv Ment Dis. Nov 1993;181(11):699-702. [Medline].

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  7. Phillips KA, Dufresne RG Jr, Wilkel CS, Vittorio CC. Rate of body dysmorphic disorder in dermatology patients. J Am Acad Dermatol. Mar 2000;42(3):436-41. [Medline].

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  10. Phillips KA, Diaz SF. Gender differences in body dysmorphic disorder. J Nerv Ment Dis. Sep 1997;185(9):570-7. [Medline].

  11. Phillips KA, Pagano ME, Menard W, Stout RL. A 12-month follow-up study of the course of body dysmorphic disorder. Am J Psychiatry. May 2006;163(5):907-12. [Medline].

  12. Nakata AC, Diniz JB, Torres AR, de Mathis MA, Fossaluza V, Bragancas CA, et al. Level of insight and clinical features of obsessive-compulsive disorder with and without body dysmorphic disorder. CNS Spectr. Apr 2007;12(4):295-303. [Medline].

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  14. Phillips KA, Taub SL. Skin picking as a symptom of body dysmorphic disorder. Psychopharmacol Bull. 1995;31(2):279-88. [Medline].

  15. Bienvenu OJ, Samuels JF, Riddle MA, Hoehn-Saric R, Liang KY, Cullen BA, et al. The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study. Biol Psychiatry. Aug 15 2000;48(4):287-93. [Medline].

  16. Phillips KA, McElroy SL, Hudson JI, Pope HG Jr. Body dysmorphic disorder: an obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both?. J Clin Psychiatry. 1995;56 Suppl 4:41-51; discussion 52. [Medline].

  17. Stein DJ, Hollander E. Dermatology and conditions related to obsessive-compulsive disorder. J Am Acad Dermatol. Feb 1992;26(2 Pt 1):237-42. [Medline].

  18. Stein DJ, Hollander E. The spectrum of obsessive-compulsive related disorders. In: Hollander E, ed. Obsessive-Compulsive Related Disorders. Washington, DC: APA Press; 1992:241-71.

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  20. Sheppard NP, O'Loughlin S, Malone JP. Psychogenic skin disease: a review of 35 cases. Br J Psychiatry. Nov 1986;149:636-43. [Medline].

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  23. Hollander E, Allen A, Kwon J, Aronowitz B, Schmeidler J, Wong C, et al. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry. Nov 1999;56(11):1033-9. [Medline].

  24. [Guideline] British Psychological Society, Royal College of Psychiatrists. Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. National Guideline Clearinghouse. 2006;[Full Text].

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  26. Krasowska D, Szymanek M, Schwartz RA, Myslinski W. Cutaneous effects of the most commonly used antidepressant medication, the selective serotonin reuptake inhibitors. J Am Acad Dermatol. May 2007;56(5):848-53. [Medline].

  27. Allen A, Hadley SJ, Kaplan A, Simeon D, Friedberg J, Priday L, et al. An open-label trial of venlafaxine in body dysmorphic disorder. CNS Spectr. Feb 2008;13(2):138-44. [Medline].

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  32. Rabe-Jablonska J. [Results of long-term observation (3-11 years) of patients with dual diagnosis: body dysmorphic disorder and delusional disorder, somatic type]. Psychiatr Pol. Mar-Apr 1998;32(2):143-53. [Medline].

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  42. Phillips KA, Dufresne RG. Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol. Jul-Aug 2000;1(4):235-43. [Medline].

  43. Phillips KA, McElroy SL, Keck PE Jr, Pope HG Jr, Hudson JI. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry. Feb 1993;150(2):302-8. [Medline].

  44. Przemyslaw P, Szepietowski J. Dysmorfofobia-zaburzenie psychiczne, z ktorym pacjenci zwracaja sie do dermatologa. Przegl Dermatol. 1999;86:171-5.

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Further Reading

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Keywords

dysmorphophobia, body dysmorphic disorder, BDD, dysmorphic syndrome, dermatological hypochondriasis, dermatological nondisease, monosymptomatic hypochondriasis, delusions of dysmorphosis

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Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Wanda M Patterson, MD, Department of Dermatology, UMDNJ-New Jersey Medical School
Wanda M Patterson, MD is a member of the following medical societies: Sigma Xi
Disclosure: Nothing to disclose.

O Joseph Bienvenu III, MD, PhD, Assistant Professor, Department of Psychiatry, Johns Hopkins University School of Medicine
O Joseph Bienvenu III, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

M Peter Chodynicki, MD, Staff Physician, Department of Psychiatry, Johns Hopkins University School of Medicine
M Peter Chodynicki, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Medical Editor

James J Nordlund, MD, Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine
James J Nordlund, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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